Pro und Kontra: Aggressive oder konservative Thrombosetherapie? – Pro aggressive Therapie

Zusammenfassung

Das postthrombotische Syndrom (PTS) stellt die Langzeitfolge einer tiefen Venenthrombose (TVT) dar, führt zu einer deutlichen Einschränkung der Lebensqualität und ist von großer sozioökonomischer Bedeutung. Die konservative Therapie aus Antikoagulation, Kompressionstherapie und Mobilisation erzielt keine direkte Auflösung des Thrombus, sodass trotz konservativer Therapie mehr als 25 % der Patienten ein PTS entwickeln. Thrombusbeseitigende Therapien haben das Potenzial, Inzidenz und Schwere des PTS zu reduzieren. Die Evidenz der chirurgischen Thrombektomie, die eine frühzeitige und rasche Rekanalisierung ermöglicht, ist schwach. Jedoch scheint diese Therapie das Risiko eines PTS bei iliofemoralen Thrombosen reduzieren zu können. Die systemische Thrombolyse, welche die Inzidenz des PTS reduzieren kann, wird aufgrund schwerer Blutungskomplikationen nicht mehr empfohlen. Neue endovaskuläre, kathetergesteuerte Verfahren ermöglichen eine lokale Lysebehandlung, eine lokale Thrombusfragmentation oder -aspiration und zeigen in den bisherigen Studien vielversprechende Erfolgsraten bei niedriger Morbidität. Jedoch liegt bisher nur 1 prospektiv-randomisierte Studie (CaVent-Studie) vor, die eine Reduktion des PTS im Langzeitverlauf zeigen konnte. Die derzeitige Datenlage empfiehlt Patienten mit einem hohen Risiko für ein PTS eine thrombusbeseitigende Therapie. Neue endovaskuläre Verfahren wie die kathetergesteuerte Thrombolyse ermöglichen eine rasche Thrombusentfernung, jedoch müssen weitere prospektiv-randomisierte Studien folgen, um den Langzeiterfolg dieser Therapie zu zeigen.

Abstract

The post-thrombotic syndrome (PTS), long-term sequelae of a deep vein thrombosis (DVT), reduces quality of life and is of great socio-economic importance. Despite conservative treatment which does not directly facilitate recanalization more than 25 % of patients develop PTS. Early thrombus removal may decrease the incidence and severity of PTS. Although the evidence for surgical thrombectomy is weak which allows an early and rapid recanalization, this therapy appears to reduce the risk of PTS and iliofemoral thrombosis. Systemic thrombolysis can reduce the incidence of PTS but it is no longer recommended due to serious bleeding complications. Previous studies with new endovascular catheter-guided procedures allowing local application of thrombolysis and thrombus aspiration displayed promising results. However, so far one prospective randomised study (CaVent study) with long-term results has revealed a significant reduction of PTS. The current evidence recommends early thrombus removal for patients at high risk for PTS. New endovascular procedures such as catheter-guided thrombolysis allow rapid thrombus removal but more prospective randomised studies are necessary to ensure the long-term success of this therapy.

Schlüsselwörter

tiefe Venenthrombose - postthrombotisches Syndrom - Thrombektomie - kathetergesteuerte Thrombolyse

Key words

deep vein thrombosis - postthrombotic syndrome - thrombectomy - catheter-directed thrombolysis

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